What is a DIEP flap breast reconstruction?
In a DIEP flap reconstruction, fat, skin and blood vessels, but not muscle, are cut from the wall of the lower belly and moved up to the chest to recreate a breast shape. The surgeon reattaches the blood vessels of the flap removed from the tummy to small blood vessels in the chest using microsurgery.
DIEP stands for deep inferior epigastric perforators, which are the blood vessels within the abdomen that are used by the surgeon to create this type of reconstruction. Prior to the operation the surgeon will refer you for a specialised CT scan that determines whether your blood vessels are viable for this type of surgery.
Because no muscle is used in a DIEP reconstruction, most women recover more quickly and have a lower risk of losing abdominal muscle strength. As the breast is recreated from your own tissue, the breast has a softer, more natural feel and appearance, compared with implant reconstructions. Also, because the new breast is formed out of tissue from the belly it leaves the tummy tighter and flatter – effectively providing a tummy tuck. This surgery does leave a long horizontal scar from hipbone to hipbone, but in most cases the scar is below the bikini line. The operation is long and very complex, and so recovery time is usually also longer than a reconstruction using an implant.
Because this procedure requires special surgical training as well as expertise in microsurgery, not all surgeons can offer DIEP and it is not available at all hospitals.
DIEP stands for deep inferior epigastric perforators, which are the blood vessels within the abdomen that are used by the surgeon to create this type of reconstruction. Prior to the operation the surgeon will refer you for a specialised CT scan that determines whether your blood vessels are viable for this type of surgery.
Because no muscle is used in a DIEP reconstruction, most women recover more quickly and have a lower risk of losing abdominal muscle strength. As the breast is recreated from your own tissue, the breast has a softer, more natural feel and appearance, compared with implant reconstructions. Also, because the new breast is formed out of tissue from the belly it leaves the tummy tighter and flatter – effectively providing a tummy tuck. This surgery does leave a long horizontal scar from hipbone to hipbone, but in most cases the scar is below the bikini line. The operation is long and very complex, and so recovery time is usually also longer than a reconstruction using an implant.
Because this procedure requires special surgical training as well as expertise in microsurgery, not all surgeons can offer DIEP and it is not available at all hospitals.
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How is the DIEP flap operation performed?
During DIEP flap surgery, an incision is made along your bikini line and a portion (flap) of skin, fat and blood vessels is taken from the lower half of your belly, moved up to your chest, and formed into a breast shape. No muscle should be moved or cut during a DIEP Flap reconstruction. The tiny blood vessels that feed the tissue of your new breast are matched to blood vessels in your chest and carefully reattached under a microscope. The surgery can take 3-5 hours for a unilateral DIEP and may be up to 6-8 hours for a bilateral DIEP. |
Who is not a good candidate for this surgery?
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AdvantagesWhat are the potential advantages of this type of surgery?
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DisadvantagesWhat are the potential disadvantages of this type of surgery?
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Post operative care after tissue flap reconstruction surgery
You'll be moved to the recovery room after surgery and then you will be admitted to a hospital room in the “high dependency” ward for intensive monitoring for 2 or 3 days. During this time nursing staff will closely monitor your heart rate, body temperature and blood pressure. As sufficient blood supply to the new breast is critical to ensuring there are no complications, for these first few days the blood flow to your new breast will be monitored constantly, using a Doppler machine to quickly detect any issues, with initial assessments occurring every 30-60 minutes for the first day or so, easing to every few hours. While you will be on bed rest for the initial postoperative period, the constant monitoring does mean that it can be difficult to sleep.
Your room may be warmed, or you might wear a heated blanket in order to assist with blood circulation. To reduce the risk of blood clots, compression stockings and a compression device will be used during the first couple of days. In addition, the bed will be positioned so that your head is elevated and your knees are flexed, to optimise blood flow. This position can feel uncomfortable after a while, and so nursing staff may be able to gently turn you on your side, with a pillow for back support. You will have a catheter to drain urine until you are able to walk to the bathroom, usually either on the 2nd or 3rd day, and you will have several drains from the incision sites in place to remove excess blood and fluid. The drains will usually be removed 2-8 days after surgery, depending on their output.
Pain management is essential to making a good recovery. You will experience some discomfort or pain and tightness in the chest area and the abdomen. If you're in pain or feel nauseated, tell your nurse so you can be given medication. Your tummy will feel tight and it will be difficult to straighten up in the first week after surgery and so you may need to move around in a slightly bent over position.
When the risk period is over you will spend the next week or so in a ward where you will be encouraged to shower and begin to move about. Nursing and physiotherapy staff will assist you in regaining mobility, and can provide advice on exercises and activities that can be done to improve your recovery and strength.
On leaving the hospital, your surgeon will give you specific instructions on post-operative care, including; caring for your surgical sites, medications to use, symptoms or concerns to look out for during the recovery period and when follow up is required.
How long is this operation?
A single (unilateral) DIEP flap procedure can take 3-5 hours, while a bilateral procedure can be from 6-8 hours long.
What is the estimated hospital stay?
For DIEP flaps, you usually stay in the hospital for about 5-7 days.
Where can this surgery be performed?
As DIEP flap surgery is relatively new and highly specialised there are a limited number of surgeons qualified to carry out this procedure. Some major public hospitals and selected private hospitals with the required micro-surgical equipment are able to offer this option. Ask your surgeon where they can perform this surgery.
Who should do this surgery for me?
This surgery involves intricate micro-surgical techniques so it is important to have this surgery performed by an experienced specialist plastic surgeon and his or her experienced team.
What stages are involved?
You'll be moved to the recovery room after surgery and then you will be admitted to a hospital room in the “high dependency” ward for intensive monitoring for 2 or 3 days. During this time nursing staff will closely monitor your heart rate, body temperature and blood pressure. As sufficient blood supply to the new breast is critical to ensuring there are no complications, for these first few days the blood flow to your new breast will be monitored constantly, using a Doppler machine to quickly detect any issues, with initial assessments occurring every 30-60 minutes for the first day or so, easing to every few hours. While you will be on bed rest for the initial postoperative period, the constant monitoring does mean that it can be difficult to sleep.
Your room may be warmed, or you might wear a heated blanket in order to assist with blood circulation. To reduce the risk of blood clots, compression stockings and a compression device will be used during the first couple of days. In addition, the bed will be positioned so that your head is elevated and your knees are flexed, to optimise blood flow. This position can feel uncomfortable after a while, and so nursing staff may be able to gently turn you on your side, with a pillow for back support. You will have a catheter to drain urine until you are able to walk to the bathroom, usually either on the 2nd or 3rd day, and you will have several drains from the incision sites in place to remove excess blood and fluid. The drains will usually be removed 2-8 days after surgery, depending on their output.
Pain management is essential to making a good recovery. You will experience some discomfort or pain and tightness in the chest area and the abdomen. If you're in pain or feel nauseated, tell your nurse so you can be given medication. Your tummy will feel tight and it will be difficult to straighten up in the first week after surgery and so you may need to move around in a slightly bent over position.
When the risk period is over you will spend the next week or so in a ward where you will be encouraged to shower and begin to move about. Nursing and physiotherapy staff will assist you in regaining mobility, and can provide advice on exercises and activities that can be done to improve your recovery and strength.
On leaving the hospital, your surgeon will give you specific instructions on post-operative care, including; caring for your surgical sites, medications to use, symptoms or concerns to look out for during the recovery period and when follow up is required.
How long is this operation?
A single (unilateral) DIEP flap procedure can take 3-5 hours, while a bilateral procedure can be from 6-8 hours long.
What is the estimated hospital stay?
For DIEP flaps, you usually stay in the hospital for about 5-7 days.
Where can this surgery be performed?
As DIEP flap surgery is relatively new and highly specialised there are a limited number of surgeons qualified to carry out this procedure. Some major public hospitals and selected private hospitals with the required micro-surgical equipment are able to offer this option. Ask your surgeon where they can perform this surgery.
Who should do this surgery for me?
This surgery involves intricate micro-surgical techniques so it is important to have this surgery performed by an experienced specialist plastic surgeon and his or her experienced team.
What stages are involved?
- The initial DIEP flap operation is 3-5 hours with 6-8 weeks recovery
- You may require 1 or more revision surgeries to shape and tweak your new breast. These are usually short day surgeries and recovery may be 1-2 weeks.
- You may be interested in the final touches of either nipple reconstruction or 3D nipple tattooing. You may also consider whether you need to reduce, lift or reshape the other breast (if a unilateral DIEP is performed), to improve symmetry with the reconstructed breast. Your surgeon will advise if this is recommended and this procedure is often done at the same time as nipple reconstruction. A breast lift and nipple reconstruction is usually a day procedure.
What are the risks?
Many of the risks associated with DIEP Flap reconstruction are the same as the risks for mastectomy. However, there are some risks that are unique to this type of surgery and these are listed below. Your surgeon should discuss these risks, as well as the general surgery risks with you well before you book in for this operation.
Tissue breakdown The flap needs a good blood supply to survive, but in rare instances, the tissue moved from your belly to your breast area won't get enough circulation and some of the tissue might die. Doctors call this tissue breakdown “necrosis.” Some symptoms of tissue necrosis include the skin turning dark blue or black, a cold or cool-to-the-touch feeling in the tissue, and even the eventual development of open wounds. You also may run a fever or feel sick if these symptoms are not addressed immediately. If a small area of necrosis is found, your surgeon can trim away the dead tissue. This is done in the operating room under general anaesthesia or occasionally in a minor procedure setting. If most or all of the flap tissue develops necrosis, your doctor may call this a “complete flap failure,” which means the entire flap would need to be removed and replaced. Sometimes the flap can be replaced within a short timeframe, but in most cases the surgical team will remove all the dead tissue and allow the area to heal before identifying a new donor site to create a new flap. Lumps in the reconstructed breast If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. These fat necrosis lumps may or may not go away on their own. If they don't, it's best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having them removed can give you greater peace of mind, as well as ease any discomfort you might have. |
Seroma or build up of fluid
Fluid may collect at the flap site. Depending on the amount of fluid, it may naturally drain away, or it may need to be syringed by the surgeon or another skilled health professional. Hernia or muscle weakness at the donor site A hernia happens when part of an internal organ (often a small piece of the intestine) bulges through a weak spot in a muscle. Most hernias happen in the abdomen. They usually happen when someone who has a weak spot in an abdominal muscle strains the muscle, perhaps by lifting something heavy. Hernias can be painful and can cause a noticeable bulge in your abdomen. Hernias usually are treated by surgically inserting mesh to support the muscle wall. The surgery is generally done on an outpatient basis. Hernias can often come back. If you have a DIEP flap, you have a small risk of a hernia. Your risk of hernia is much lower with a DIEP flap than with any type of TRAM flap. This is because a DIEP flap uses no muscle to rebuild your breast. Still, as with any abdominal surgery, there is some risk of hernia. Abdominal wound infection and dehiscence The infection may be treated with simple antibiotics, rarely the skin of the lower abdomen completely breaks down and requires repeated visits to the theatres for debridement of the non viable tissue. If this occurs, you may need a special dressing called a VAC dressing to cover the wound. Occasionally there isn’t enough loose skin to close the lower abdominal wound, if this occurs you may require a skin graft to get a healed wound. This leaves an unsightly contour defect but can be revised and corrected around 6 months later. |
Recovery advice
It can take about 6 to 8 weeks to recover from DIEP flap reconstruction surgery. Some doctors recommend that you wear a compression girdle for up to 8 weeks after surgery. A support bra or bandage may be worn to help reduce swelling and support the reconstructed breast.
Because this type of reconstruction involves several incision sites it may take longer to recover than if you have had a less invasive procedure. You will have at least three wounds to manage including the chest, the abdomen and the belly button and drains in the chest and the groin area. The output of the drains will be carefully monitored, and depending upon your surgeon’s preference, may be removed before you are discharged from the hospital, or you may need to be shown how to care for and measure the output at home.
For most women the most challenging recovery area is the abdominal wound. You may feel very tight and feel that you need to bend over when walking and have your legs up and back supported when sitting or reclining. It can be especially difficult getting in and out of bed. The hospital physiotherapist can show you how to move until your abdominal area heals and will usually provide you with exercises you can do throughout your recovery period to improve mobility and regain strength. If you have severe pain, ask your doctor for pain relief.
You may be prescribed painkillers, antibiotics and anti-inflammatory drugs when you are first discharged from hospital. It is vital to use these as prescribed to successfully manage any pain and to reduce the risk of infection.
It's important to take the time you need to heal. Follow your doctor's advice on when to start stretching exercises and your normal activities. You should avoid lifting anything heavy (more than 10kg), strenuous sports, and sexual activity for about 6 weeks after DIEP flap reconstruction.
Post-operative recovery can take longer if complications occur, so it is important to get adequate rest, make sure you follow your surgeon’s directions and exercise within the limits of comfort – if you feel any pain or pulling, especially around the wound sites, stop.
It can take up to twelve months to completely heal and for scars to fade and for you to get a good indication of how your new breasts will settle into your body. You might feel further surgery to refine the shape of your new breast mound is necessary but it is a personal choice. Revision surgery can take place anytime from three months post-surgery. When you have achieved the desired shape and your breasts are settled into their shape, you may like to consider the finishing touched of reconstructed nipples or 3D nipple tattoos.
Because this type of reconstruction involves several incision sites it may take longer to recover than if you have had a less invasive procedure. You will have at least three wounds to manage including the chest, the abdomen and the belly button and drains in the chest and the groin area. The output of the drains will be carefully monitored, and depending upon your surgeon’s preference, may be removed before you are discharged from the hospital, or you may need to be shown how to care for and measure the output at home.
For most women the most challenging recovery area is the abdominal wound. You may feel very tight and feel that you need to bend over when walking and have your legs up and back supported when sitting or reclining. It can be especially difficult getting in and out of bed. The hospital physiotherapist can show you how to move until your abdominal area heals and will usually provide you with exercises you can do throughout your recovery period to improve mobility and regain strength. If you have severe pain, ask your doctor for pain relief.
You may be prescribed painkillers, antibiotics and anti-inflammatory drugs when you are first discharged from hospital. It is vital to use these as prescribed to successfully manage any pain and to reduce the risk of infection.
It's important to take the time you need to heal. Follow your doctor's advice on when to start stretching exercises and your normal activities. You should avoid lifting anything heavy (more than 10kg), strenuous sports, and sexual activity for about 6 weeks after DIEP flap reconstruction.
Post-operative recovery can take longer if complications occur, so it is important to get adequate rest, make sure you follow your surgeon’s directions and exercise within the limits of comfort – if you feel any pain or pulling, especially around the wound sites, stop.
It can take up to twelve months to completely heal and for scars to fade and for you to get a good indication of how your new breasts will settle into your body. You might feel further surgery to refine the shape of your new breast mound is necessary but it is a personal choice. Revision surgery can take place anytime from three months post-surgery. When you have achieved the desired shape and your breasts are settled into their shape, you may like to consider the finishing touched of reconstructed nipples or 3D nipple tattoos.
Reviewed by:
Dr Pouria Moradi
MBBS BSc (Med)
MRCS (Eng) FRACS (plas)
Reference sources:
Breastcancer.org:
http://www.breastcancer.org/treatment/surgery/reconstruction/types/autologous/diep
Cancer Research UK:
http://www.cancerresearchuk.org/about-cancer/type/breast-cancer/treatment/surgery/reconstruction/breast-reconstruction-using-body-tissue
Australian Society of Plastic Surgeons:
http://www.plasticsurgeryfoundation.org.au/patient-information/procedures
Cancer Australia:
http://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/treatment/breast-reconstruction/types/using-diep-flap/post-operative-recovery-after-diep-flap-breast-reconstruction
Randwick Plastic Surgery: Patient Information Sheets
http://www.randwickplasticsurgery.com.au
Dr Pouria Moradi
MBBS BSc (Med)
MRCS (Eng) FRACS (plas)
Reference sources:
Breastcancer.org:
http://www.breastcancer.org/treatment/surgery/reconstruction/types/autologous/diep
Cancer Research UK:
http://www.cancerresearchuk.org/about-cancer/type/breast-cancer/treatment/surgery/reconstruction/breast-reconstruction-using-body-tissue
Australian Society of Plastic Surgeons:
http://www.plasticsurgeryfoundation.org.au/patient-information/procedures
Cancer Australia:
http://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/treatment/breast-reconstruction/types/using-diep-flap/post-operative-recovery-after-diep-flap-breast-reconstruction
Randwick Plastic Surgery: Patient Information Sheets
http://www.randwickplasticsurgery.com.au